Provider Demographics
NPI:1821842733
Name:LEWIS, CHANNON BROWN (DC)
Entity Type:Individual
Prefix:DR
First Name:CHANNON
Middle Name:BROWN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 ANASTASIA BLVD # A
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-4508
Mailing Address - Country:US
Mailing Address - Phone:904-824-8353
Mailing Address - Fax:
Practice Address - Street 1:905 SAINT JOHNS AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-4649
Practice Address - Country:US
Practice Address - Phone:386-328-2710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14652111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor